Generic Preventive Care/ Safe Harbor Drug Program List Preventive care/safe harbor drugs are drugs that can help keep you from developing a health condition or related complications of a health condition. The Generic Preventive Care/Safe Harbor Drug Program includes certain generic drugs in selected prescription drug categories. For applicable plans, the generic preventive care/safe harbor drugs included on this list are available at 100% coverage with the deductible waived, when purchased at an In-Network pharmacy. All generic drugs listed below are subject to the quantity and day supply limits included with your benefit plan (typically up to a 90-day supply at mail order). Please refer to your benefit plan for a complete list of benefits, including specific exclusions. GENERIC NAME ACEBUTOLOL HCL AFEDITAB CR ALENDRONATE SODIUM AMLODIPINE BESYLATE AMLODIPINE BESYLATE-BENAZEPRIL AMLODIPINE-ATORVASTATIN AMLODIPINE-OLMESARTAN AMLODIPINE-VALSARTAN AMLODIPINE-VALSARTAN-HCTZ ASPIRIN-DIPYRIDAMOLE ER ATENOLOL ATENOLOL-CHLORTHALIDONE ATORVASTATIN CALCIUM BAL-CARE DHA BENAZEPRIL HCL BENAZEPRIL-HYDROCHLOROTHIAZIDE BETAXOLOL HCL BISOPROLOL FUMARATE BISOPROLOL-HYDROCHLOROTHIAZIDE CALCIUM PNV CANDESARTAN CILEXETIL CANDESARTAN-HYDROCHLOROTHIAZID CAPTOPRIL CAPTOPRIL-HYDROCHLOROTHIAZIDE CARTIA XT CHLOROTHIAZIDE CHLORTHALIDONE CHOLESTYRAMINE CHOLESTYRAMINE LIGHT CLOPIDOGREL DRUG CLASSIFICATION
C-NATE DHA COLESTIPOL HCL COMPLETE NATAL DHA COMPLETENATE DILTIAZEM 12HR ER DILTIAZEM 24HR CD DILTIAZEM 24HR ER DILTIAZEM ER DILTIAZEM HCL DILT-XR DIPYRIDAMOLE DOTHELLE DHA ELITE-OB ENALAPRIL MALEATE ENALAPRIL-HYDROCHLOROTHIAZIDE EPROSARTAN MESYLATE FELODIPINE ER FENOFIBRATE FENOFIBRIC ACID FLUVASTATIN ER FLUVASTATIN SODIUM FOCALGIN 90 DHA FOCALGIN CA FOLBECAL FOLIC ACID FOLIVANE-OB FOSINOPRIL SODIUM FOSINOPRIL-HYDROCHLOROTHIAZIDE GEMFIBROZIL HEMENATAL OB HEMENATAL OB + DHA HYDROCHLOROTHIAZIDE IBANDRONATE SODIUM INDAPAMIDE IRBESARTAN IRBESARTAN-HYDROCHLOROTHIAZIDE ISRADIPINE JANTOVEN LEVOMEFOLATE DHA LISINOPRIL LISINOPRIL-HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM LOSARTAN-HYDROCHLOROTHIAZIDE LOVASTATIN Page 2 of 5
MACNATAL CN DHA MATZIM LA METHYCLOTHIAZIDE METOLAZONE METOPROLOL SUCCINATE METOPROLOL TARTRATE METOPROLOL-HYDROCHLOROTHIAZIDE MOEXIPRIL HCL MOEXIPRIL-HYDROCHLOROTHIAZIDE MYNATAL MYNATAL ADVANCE MYNATAL PLUS MYNATAL-Z MYNATE 90 PLUS NADOLOL NADOLOL-BENDROFLUMETHIAZIDE NEWGEN NIACIN ER NICARDIPINE HCL NIFEDICAL XL NIFEDIPINE NIFEDIPINE ER NIMODIPINE NISOLDIPINE OBSTETRIX DHA OLMESARTAN MEDOXOMIL OLMESARTAN-AMLODIPINE-HCTZ OLMESARTAN-HYDROCHLOROTHIAZIDE PERINDOPRIL ERBUMINE PINDOLOL PNV 29-1 PNV OB+DHA PNV-DHA PNV-DHA + DOCUSATE PNV-FERROUS FUMARATE-DOCU-FA PNV-OMEGA PNV-SELECT PNV-VP-U PR NATAL 400 PR NATAL 400 EC PR NATAL 430 PR NATAL 430 EC PRAVASTATIN SODIUM PRENA1 CHEW Page 3 of 5
PRENA1 PEARL PRENA1 TRUE PRENAISSANCE PRENAISSANCE NEXT PRENAISSANCE PLUS PRENATABS FA PRENATABS RX PRENATAL PLUS PRENATAL VITAMIN PLUS LOW IRON PRENATAL-U PREPLUS PRETAB PREVALITE PROPRANOLOL HCL PROPRANOLOL HCL ER PROPRANOLOL-HYDROCHLOROTHIAZID QUINAPRIL HCL QUINAPRIL-HYDROCHLOROTHIAZIDE RALOXIFENE HCL RAMIPRIL RELNATE DHA RISEDRONATE SODIUM RISEDRONATE SODIUM DR ROSUVASTATIN CALCIUM RULAVITE DHA SE-NATAL 19 SIMVASTATIN TARON-C DHA TARON-PREX PRENATAL TAZTIA XT TELMISARTAN TELMISARTAN-AMLODIPINE TELMISARTAN-HYDROCHLOROTHIAZID THRIVITE 19 TICLOPIDINE HCL TIMOLOL MALEATE TRANDOLAPRIL TRANDOLAPRIL-VERAPAMIL ER TRINATAL GT TRINATAL RX 1 TRINATE TRI-TABS DHA TRIVEEN-DUO DHA TRUST NATAL DHA Page 4 of 5
ULTIMATECARE ONE ULTIMATECARE ONE NF VALSARTAN VALSARTAN-HYDROCHLOROTHIAZIDE VEMAVITE-PRX 2 VERAPAMIL ER VERAPAMIL ER PM VERAPAMIL HCL VERAPAMIL SR VINATE CARE VINATE DHA VINATE II VINATE ONE VINATE ULTRA VINATE-M VIRT-ADVANCE VIRT-C DHA VIRT-NATE VIRT-NATE DHA VIRT-PN VIRT-PN DHA VIRT-PN PLUS VIRT-SELECT VIRT-VITE GT VITAFOL-OB VOL-NATE VOL-PLUS VOL-TAB RX VP-CH PLUS VP-CH-PNV VP-GGR-B6 VP-HEME OB VP-HEME ONE WARFARIN SODIUM ZATEAN-CH ZATEAN-PN DHA ZATEAN-PN PLUS ZINGIBER Page 5 of 5